Clinical Psychiatry

Erectile dysfunction (ED)

ICD-10F52.2Failure of genital response
DSM-5-TRF52.21Erectile Disorder

1. Definition and nosology

Erectile Dysfunction (ED; ICD-11: HA01.1 Male erectile dysfunction; DSM-5-TR: F52.21) — persistent difficulty in obtaining or maintaining an erection sufficient for sexual intercourse. Duration ≥ 6 months, in most attempts.

2. History

  • 1998 — FDA approval of sildenafil (Viagra) — revolution in ED treatment.
  • AUA (American Urological Association) Guideline (Burnett 2018, 2024 update).
  • EAU (European Association of Urology) Guidelines.

3. Epidemiology

  • 5–10% at age 40, 50%+ at age 70.
  • Risk factors: diabetes, cardiovascular disease (ED as cardiovascular early marker), hypertension, hyperlipidemia, smoking, obesity, depression, antidepressants.

4. Etiology and pathogenesis

  • Organic (~70%) — vascular, neurogenic, endocrine (hypogonadism), medication-related.
  • Psychogenic (~10%) — performance anxiety, relationship problems, depression.
  • Mixed (~20%).
  • Princeton III Consensus (Nehra 2012) — ED an early cardiovascular marker, cardiac risk assessment important.

5. Clinical features

  • Difficulty obtaining or maintaining erection.
  • Presence or absence of morning or nighttime erections (for psychogenic vs organic differentiation).
  • Relationship and emotional burden.

6. Diagnosis

6.1 Unified diagnostic criteria (AUA 2018 · EAU)

A. Persistent difficulty obtaining and/or maintaining erection.

B. Duration ≥ 6 months, in most attempts.

C. Distress or relationship impairment.

6.2 Differences between sources

  • AUA 2018/2024 and EAU — stepwise approach.

6.3 Diagnostic algorithm

  • Clinical interview (sexual and medical history, relationships).
  • IIEF (International Index of Erectile Function) / SHIM.
  • Laboratory — morning testosterone, glucose, HbA1c, lipid profile, prolactin, thyroid.
  • Cardiovascular evaluation.
  • Penile ultrasound (vascular suspicion) — selective.

6.4 Differential diagnosis

Condition Distinguishing feature
Hypogonadism Low testosterone + symptoms.
Premature ejaculation (HA03.0) Ejaculation time.
Hypoactive sexual desire (HA00) Decreased desire dominant.
Peyronie’s disease Penile curvature and pain.

7. Examination and assessment

  • IIEF.
  • Medical and laboratory (above).
  • Cardiac evaluation (ECG, stress test if needed).

8. Treatment

8.1 General principles (AUA 2018/2024 · EAU stepwise)

  • 1st line:
  • Lifestyle — smoking cessation, weight, physical activity, cardiovascular management;
  • PDE5 inhibitors — sildenafil (25–100 mg), tadalafil (5–20 mg as needed or 2.5–5 mg daily), vardenafil, avanafil; absolutely contraindicated with nitrates; caution with α-blockers.
  • 1st line (in hypogonadism): Testosterone replacement therapy (TRT) — only for confirmed hypogonadism (≥ 2 morning measurements low + symptoms); monitoring PSA and hematocrit.
  • Second-line:
  • Intracavernosal alprostadil (PGE1);
  • Transurethral alprostadil (MUSE);
  • Vacuum erection device.
  • Third-line: penile prosthesis (semirigid or inflatable); high satisfaction.
  • Psychotherapy — in performance anxiety; couple therapy.
  • Antidepressant-induced ED — bupropion, mirtazapine, vortioxetine alternative; sildenafil adjunct (Nurnberg JAMA 2003).

8.2 Treatment methods

  • PDE5 Inhibitors — Phosphodiesterase 5 inhibitor; absolutely contraindicated with nitrates.
  • Intracavernosal Alprostadil — PGE1; if PDE5 fails.
  • Vacuum Device — Non-invasive; use with caution in anticoagulant use and bleeding disorders.
  • Penile Prosthesis — Refractory ED; high satisfaction.
  • International Index of Erectile Function (IIEF) — Severity scale.

8.3 Differences between sources

  • Burnett A.L. et al. AUA Guideline. J Urol 2018, 2024 update.
  • Salonia A. et al. EAU Guidelines 2023.

9. Prognosis

PDE5 with 70% efficacy; refractory cases 2nd–3rd line; cardiovascular risk management reduces mortality.

10. Myths and misconceptions

Myth 1: “ED is a normal part of aging, requires no treatment”

Evidence: ED is an early cardiovascular marker; active intervention is essential.

Myth 2: “Over-the-counter ‘natural’ potency enhancers are safe”

Evidence: FDA warnings — many “natural” products contain undeclared sildenafil/tadalafil — interaction with nitrates, risk of death.

Myth 3: “Testosterone replacement therapy is needed for every ED patient”

Evidence: AUA — only in confirmed hypogonadism; routine TRT not recommended.

Myth 4: “Shock wave therapy (Li-ESWT) is standard treatment”

Evidence: AUA 2024 — under investigation; not standard first-line.

Myth 5: “Yohimbine is an effective natural alternative”

Evidence: Ernst E., Pittler M.H. J Urol 1998;159(2):433–436 — small effect, side effects of anxiety and hypertension; PDE5 superior.

11. Sources

  • WHO. ICD-11. HA01.1 Male erectile dysfunction. 2024.
  • APA. DSM-5-TR. 2022.
  • Burnett A.L. et al. Erectile Dysfunction: AUA Guideline. J Urol 2018;200(3):633–641.
  • Salonia A. et al. EAU Guidelines on Sexual and Reproductive Health 2023.
  • Nehra A. et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc 2012;87(8):766–778.
  • Yuan J. et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol 2013;63(5):902–912.